The trust which runs Grimsby’s Diana, Princess of Wales Hospital has been severely criticised at an inquest following the death of a six-day-old baby.

Although assistant coroner Jane Eatock said every effort had been made to save infant Roman Ling, the serious incident report by the Trust into his death had caused extreme distress and anxiety to the baby’s family and was “illogical.”

Tragically, Roman died six days after being born by emergency Caesarean at the maternity hospital on July 10 last year.

Today Health Secretary, Jeremy Hunt has announced all deaths at birth and babies left with serious injuries will be investigated by the Healthcare Safety Investigations Branch, set up earlier this year.

There are an estimated 1,000 cases a year where babies unexpectedly die or are left with severe brain injury. That is out of nearly 700,000 births.

All unexplained cases of serious harm or death will now be independently investigated.

Grimsby parents, Kirsty Emptage and Carl Ling had the devastating decision to make to agree to the removal of Roman’s breathing tube to see if their son was able to breathe by himself.

The couple had decided, after medical advice, that if Roman was unable to breathe unaided, they would not ask for the tube to be replaced.

In her narrative conclusion, Mrs Eatock said the infant died from hypoxic-ischaemic encephalopathy, which meant his brain was starved of oxygen.

Roman Ling undergoing treatment in hospital before his tragic death

She said the death “arose from a difficult caesarean birth contributed to or caused by and underlying congenital infection".

But at the end of the two-day inquest at Cleethorpes Town Hall, she said it had been a difficult case, not just because of the tragic events, but the apparent contradiction between the results of the post mortem examination and “too many experts spoiling the broth".

She said there had been “differences in interpretation and discrepancies” in evidence heard at the inquest.

But she added: “There was nothing sinister and no evidence of a lack of transparency. We have had extremely good co-operation from those involved."

The assistant coroner apologised to Roman’s family for the difficulties and thanked all the hospital staff who had given their evidence in a “helpful, co-operative and open” way.

Northern Lincolnshire and Goole NHS Foundation Trust has admitted liability for Roman’s death. In the Serious Incident Investigation report it offered its ‘sincere apologies for the sad loss’ of Roman.

Mrs Eatock praised Roman’s parents for the “great dignity and respect” shown at the inquest especially mum Kirsty Emptage, who gave evidence.

Cleethorpes Town Hall

She said up until 8pm on July 10 the mother had experienced a normal pregnancy and Miss Emptage was a “healthy mother".

Her waters broke around 8.10pm but Roman’s low heart rate was detected quickly.

Midwives Rachel Bailey and Sister Michelle Barford responded immediately with conservative measures which resulted in a return to a normal heart rate in the foetus.

But at 8.18pm the baby had presented himself facially, which is an extremely rare condition.

At 8.25pm a Category 1 emergency was declared and the caesarean operation was carried out by a specialist team.

The assistant coroner said she “did not find any breaches” in procedures and “everything was done appropriately” and there had been “no failings contributing to the death.”

She said the registrar in charge of the delivery Dr Awahid Uddin, had hoped the baby would rotate for a normal delivery to avoid a caesarean birth.

Roman was transferred to the neo-natal unit at Sheffield’s Royal Hallamshire Hospital for specialist treatment.

On July 14, he underwent an MRI scan and Carl and Kirsty were told their son would die if his breathing tube was removed.

The maternity unit at the Diana Princess of Wales Hospital in Grimsby where baby Roman was born

Two days later, on the advice of doctors, the couple agreed to the removal of Roman’s breathing tube to see if their son was able to breathe by himself. However, Roman died in his parents' arms shortly afterwards.

Kirsty wept as she told the hearing: "I should be watching him taking his first steps and listening to him saying his first words."

Following the tragedy, Northern Lincolnshire and Goole Hospitals NHS Foundation Trust carried out a serious incident investigation and compiled a report within 12 weeks, which is the deadline set by the Trust’s policies following a tragic death.

Mrs Eatock said: “I am very disappointed by the quality of the serious incident report.”

It stated the ‘root cause’ of Roman’s death was a delay in undertaking a caesarean following the discovery that Roman had a low heartbeat. The report said Roman was delivered 45 minutes after this discovery, compared to the recommended nine minutes.

The position Roman was in during birth meant a caesarean was necessary and a doctor’s decision to continue to push for a natural delivery was ‘inappropriate’, the report found.

She said the report had been released and shared with the family before the post mortem examination results have even been revealed.

The report claimed there had been delays in treatment and raised uncertainty by stating it was “unclear the exact position” of the baby.

Mrs Eatock said: “I find no logic in this.”

She added: “It is an extremely damaging fact to record and release and is damaging to the family.”

Assistant Coroner Jane Eatock

She said the Trust did not have the results of the post mortem examination.

“Both parties were working in isolation and sadly there was not a joining up of these two positions at an earlier stage,” she said.

The assistant coroner said all the measures taken by the medical team were appropriate based on clinical judgement.

The birth led to a lack of oxygen to the baby which caused his death.

A post mortem examination revealed Roman suffered from congenital pneumonia and there was widespread E-Coli found later in his body causing sepsis.

Roman’s placenta, which contained the infection, had not been examined for histology because it was disposed of after the birth.

Mrs Eatock said that had there been an opportunity to examine the placenta the pathologists could have proved the type of infection that was present.

She said: “This could have explained why there was low heart beat and why there was a difficult presentation.”

She urged the Trust that in future reports to headline it is a “preliminary report” or make it clear it is written before post mortem examination results are known.

She criticised the Trust for issuing the report to a distressed couple who had lost “their much-wanted baby".

“Some of that distress could have been reduced had there been more consideration of the facts,” she said.

The assistant coroner shook hands with parents Carl Ling and Kirsty Emptage at the conclusion of the inquest to pass on her condolences.

After the hearing, Kirsty said: "Carl, our daughter and I are emotionally and physically exhausted. We have been fighting for answers as to what happened to our beautiful son for the last 16 months.

"Our primary focus, because nothing will ever bring Roman back, besides trying to function on a daily basis, is to ensure that there is a recognition for the mistakes that were made that led to this and that a robust plan is put in place by the trust to ensure no other family experiences the same tragedy as our families have faced."

She added: "We have faced hurdles in our quest for the truth. We have challenged the subsequent investigations because we both felt that things had gone wrong."

Kirsty said they both wanted to share the love of their son and "wanted him from the second we found out we were expecting him".

She said: "We have been prevented from living and prevented from grieving for our most precious gift who we never saw take his first step or speak his first word. This is a tragedy we will never overcome. However, with the answers now clear, we hope to move forward for the sake of our daughter and our family and grieve for our beautiful boy.”

After the inquest, Dr Kate Wood, acting medical director at Northern Lincolnshire and Goole NHS Foundation Trust said: “We would like to express our sincere condolences to the family of Roman Ling after his tragic death.

“A detailed investigation was carried out into the circumstances leading up to Roman’s death in July 2016 and a number of recommendations were made around documentation and handover which have already been implemented.

“Whilst none of these actions would have changed the outcome for Roman the Trust has taken learning points from his case which will help to improve practice in the future."